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An argument for starvation

I believe that adults have the right to decide freely whether they want to live or die, and to have that decision respected. The critical – and difficult – part is that word “freely”. Imagine that you have a friend in an abusive relationship. She is so miserable that she openly says she will let her abuser kill her; she has no intention or will to leave him. In that case, the decision to die may be perfectly rational, but it isn’t taken “freely” at all. Another person has destroyed your friend’s ability to value her survival, and rather than leave her to the death she says she accepts, you will maybe feel that she should be forcibly removed from the influence of her abuser before she can be seen as competent to make life-or-death decisions.

Now, what if instead of another person being the source of self-destructive tendencies, it was a mental illness? A high court judge has ruled that a 32-year-old woman with severe anorexia can be force fed, against her wishes and the wishes of her parents. Named as “E” by the court, she is described as “intelligent”; she’s a former medical student. She would be a perfect example of competence when it comes to choices about her own body and life, except that she has a disease that makes her morbidly afraid of eating: in other words, the treatment she is refusing is food, and because anorexia is a disease that makes the sufferer fearful of eating, the anorexic is by definition not competent to make that decision.

The detail that tips me away from thinking the court should respect her wishes is the judge’s comment that, “She does not seek death, but above all she does not want to eat or be fed.” It’s not completely fanciful to think of anorexia as something like abuser exerting control over the victim. In this post at Vagenda, writer Emer describes how the disease “tried to pay me an unwelcome visit”. She relates a dialogue with the disease as though it’s something outside herself, a hostile presence to be stalled and rejected – and she has successfully pushed it out of her life. Not every sufferer can do that though, and the detail that tips me in favour of thinking the court should accept E’s wishes is that she seems to be one of those whose condition is incurable.

The NHS says that 20-30% of those with anorexia do not respond to treatment; one in 20 will die of malnutrition. At 32 and with two decades of affliction, E is certainly in that first category, and only medical compulsion is keeping her out of the second. She is in all likelihood going to die, and force feeding will only be an extra interval of unpleasantness before death. The moment of questioning her competency has possibly passed: after 20 years, it seems likely that all interventions have been attempted and all have failed. She still does not want to eat or be fed. The disease isn’t external to E, it is in her and of her, and if she seems to speak with the voice of anorexia, that is her voice too and should be listened to.

9 thoughts on “An argument for starvation”

I’m all for people killing themselves if they want to; their choice should be respected and there should be no stigma attached to suicide. But I feel that people who’ve made it clear that they want to die should just do it. If an anorexic wants to end their life, they should be given means to do so (a gun, a rope, poison, whatever). If they can’t actively end their life there and then, then they don’t actually want to die and they should be given all the treatment available. Dying of starvation when 2/3 of the world’s population doesn’t get enough food is a sickening display of western privilege and a slap in the face to a large part of humanity. It’s taking the cosseting of the first world’s middle class a step too far.

Many, many issues with your position here. First of all, that you seem to associate “anorexia” with “voluntary over-dieting”. It isn’t: it’s an extreme, pathological aversion to eating coupled with a highly disordered view of your own body. It takes a deeply unsympathetic mindset to view such suffering as a “slap in the face” to anyone – anorexia sufferers are catching the brunt of western thinness ideals and overconsumption culture anyway. They certainly don’t need your opprobrium on top of their own self-loathing.

And secondly, you show a complete ignorance of the treatment issues: patient consent is such an important principle, it shouldn’t be violated just because someone’s disease has offended your over-delicate principles. I truly hope you never have to help anyone going through this deadly, agonising and sly illness. I don’t think they would survive your idea of compassion.

I read about this in the Telegraph yesterday and didn’t know what to make of it. I suffered from severe anorexia in my teens and was, at one stage, force-fed after refusing to eat for an extended period of time. This was in 1987 and treatment was extremely primitive. I was on a normal children’s ward, albeit in the isolation section, and the process involved a naso-gastric tube (which I pulled out and had forced back in several times) and the denial of “privileges” (seeing my parents, having books, people talking to me, eventually even having the light on – I was twelve at the time). There was no psychological therapy offered. The attitudes of the nurses were pretty much summed up by the first comment to this post (“How can you do this when there are children here fighting for their lives?” Although the majority of children in a ward of this level actually just had broken arms or tonsilitis…). Anyhow, I digress. A lot. The point I wanted to make was that people might underestimate just how invasive and violating force-feeding is to someone suffering from anorexia. It’s not just about forcing someone to live. It can be taking away a person’s identity. I think your point about the anorexic voice not necessarily being separate from an individual’s voice is very valid. But then, when I had treatment again ten years later, it was in a much more advanced treatment centre which didn’t offer force-feeding. So I had the privilege of watching someone literally starve themselves to death, and to do so felt so wrong.
Well. I might post about this myself later rather than blab on about myself here (typical cosetted middle-class ex-anorexic – it’s, like, all about me). But than you for such a thoughtful post, and such a good response to the initial comment.

Thanks, Sarah, for both the initial post, and your reply to the above comment. My thoughts are along the same lines as you, and I would like to comment further after a little more thought and time. I have been in a very similar position to ‘E’; I was forcibly restrained and sedated and tube-fed. The bringing to public awareness and resulting discussions have brought up a lot of feelings for me, which I am still thinking through.

This is an incredibly difficult one. I think there is a tendency for people, especially those who don’t have any first hand experience of a condition such as anorexia, to assume that as it is a “psychological” disorder E’s wish to refuse treatment must be inherently irrational, and the instinctive reaction is that the judgement was correct. Well that was my initial reaction when I read about the case anyway.
But if E is indeed one of the minority who will not respond to treatment then I guess it’s not necessarily any less rational for her to want to take control of ending her life than it is for someone who has cancer, MS or any other terminal condition which is likely to lead to a slow, painful and debilitating death. So as someone who is at least sympathetic to, if not totally persuaded by, the arguments for legalising assisted suicide I’m less sure of my view than I was initially, although I do think that we should always err on the side of preserving life.

I’m don’t support FA or pro-ana views. I don’t think it is always right to follow a patient’s instructions. People in mental extremis may take potentially lethal actions which they later are glad did not have the effect desired at the time – for example, in this study of survivors of suicide attempts, none of them made further efforts to kill themselves. People who at one point were sincere about self-destruction came to hold a different opinion about the value of survival. There is a conflict in this case, and it is insulting to E, her family and the medical staff caring for her to refuse to acknowledge it.

I think the judge was absolutely right – this young woman had hopes and dreams for a career, a family and children. That she wants to die is simply an aspect of the anorexia itself, and something she may be able to recover from. As a society, we can’t allow a young women to waste away because we’ve failed to provide the conditions for her to get better. That would be morally wrong.

Someone very close to me had anorexia and wanted to die – that she didn’t is testament to the (somewhat mad) determination of doctors and relatives to pull her through. Now she has career family etc. Her family carefully treated it as an ‘illness’, quite separate to the person (not tied up with their identity) – this is what enabled her to get better. She saw that some of her attitudes were tied up with the illness, and was eventually able to reject them as ‘other’. The problem with this patient is that she’s been anorexic for so long, her family aren’t strong enough to find and fight for her personality, independent of her illness.

Anorexia is proven to be a mental illness, with symptoms which repeat themselves time and again in different patients. It’s not an inherent part of the patient. I think your assertion that the views of the anorexic are also the views of the person is quite wrong. You’re then locking that person into an identity which by definition involves anorexia. How can they ever break free from that?

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About me

I’m a columnist, critic and feature writer with bylines at the New Statesman, the Guardian, the Spectator, the Independent, Eurogamer, Stylist, Grazia, Elle and more. Regular TV and radio appearances, including Newsnight and Today. Available for teaching and talks. Anti-fun feminist. Represented by Juliet Pickering at Blake Friedman.